**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 55 residents. The sample included 14 residents, with six reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 40 remained free from avoidable falls when staff failed to provide R40 with the necessary equipment to ensure safety, including a call light and mobility devices, on two separate occasions which resulted in falls on both occasions. This placed the resident at risk for avoidable injury. Findings included: - R40's Electronic Medical Record (EMR) documented diagnoses of heart failure, hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R40's admission Minimum Data Assessment (MDS), dated [DATE], documented R40 had intact cognition, and required extensive assistance from two staff for bed mobility, transfers, ambulation, dressing, and toileting; R40 required extensive assistance from one staff for personal hygiene. The MDS further documented R40 had unsteady balance and no falls since admission. The Quarterly MDS, dated 02/06/24, documented R40 had intact cognition, required substantial assistance with toileting, dressing, and transfers, and required supervision with mobility. R40 did not ambulate. The MDS further documented R40 had a functional impairment in both lower limbs. R40 had two falls since the last assessment. The Fall Risk Assessments, dated 08/2/23, and 01/09/23 documented a moderate risk for falls. R40's Care Plan, dated 01/29/24 and initiated on 08/03/23, directed staff to ensure his walker and wheelchair are within his reach and easy access. The update, dated 08/22/23, directed staff to check on R40 frequently and ensure safety and call light placement. The update, dated 11/14/23, directed staff to place a call light box above the resident's bed and a clip to the call button to prevent any tripping hazard. The update, dated 01/09/24, directed staff the ensure R40's wheelchair was within reach before exiting the room. The Root Cause Analysis Investigation, dated 11/11/23 at 01:35 AM, documented R40 was found lying on the carpeted floor next to his bed, face down with his legs extended. His call light was next to him. R40 stated his call light was on the floor and he leaned over to retrieve it which caused him to roll out of bed. The investigation further documented R40 sustained a laceration to the top of his head, which required first aid. R40 was taken to the local hospital and the laceration was cleansed and glued. The staff were educated to ensure R40's call light was within reach before exiting the room. The Root Cause Analysis Investigation, dated 01/09/24 at 12:21 PM, documented R40 hollered for assistance and was found on the floor in his room. R40 stated he tried to get out of the recliner to use his walker to go to the bathroom, but both the walker and wheelchair were not within reach, and he stated he could not call for assistance because his call light was not within reach either. The staff was educated to ensure his call light and wheelchair were within reach before exiting his room. On 04/15/25 at 08:29 AM, observation revealed R40 in the bathroom. Licensed Nurse (LN) H told R40 to use the grab bar beside the toilet to assist him in standing up. R40 stood up, LN H performed personal care then assisted R40 into his wheelchair. LN H pushed R40 by his recliner, gave him his call light, and told him to call if he needed assistance. On 04/10/24 at 12:15 PM, Certified Nurse Aide (CNA) R stated R40 did not have any falls when she worked and said she always made sure R40 had his call light before she left the room and stated they are trained regarding abuse and neglect yearly. On 04/15/24 at 08:40 AM, LN H stated R40 called when he required assistance. LN H said R40 had not had any falls on her shift, and stated they have ongoing training regarding falls and abuse and neglect. On 04/15/24 at 02:14 PM, Administrative Nurse D stated, R40 should not have been left without access to his call light, staff were educated and another call light was placed where it would be accessible. The facility's policy Falls revised 10/12/22 documented that residents would be identified for risk of falls and interventions would be implemented to reduce the risk The facility failed to ensure R40 remained free from avoidable falls. This placed the resident at risk for injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 55 residents. The sample included 14 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to establish the physician-ordered fluid restriction for one resident, Resident (R) 40. This placed the resident at risk for dehydration (a harmful reduction in the amount of water in the body) or fluid overload (too much fluid in the body). Findings included: - The Electronic Medical Record (EMR) documented R40 had diagnoses of heart failure (the heart does not pump blood as well as it should), hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and anxiety (metal or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R40's admission Minimum Data Assessment (MDS), dated [DATE], documented R40 had intact cognition. R40 required extensive assistance from two staff for bed mobility, transfers, ambulation, dressing, and toileting. R40 required set-up assistance for eating. The Quarterly MDS, dated 02/06/24, documented R40 had intact cognition. R40 required substantial assistance with toileting, dressing, and transfers and supervision with mobility. R40 required set-up assistance for eating. R40's Care Plan, dated 01/29/24 and initiated on 08/15/23 documented R40 was on a regular diet with an 1800 milliliter (ml) fluid restriction. R40 would receive 75 percent (%) of his fluid from nutrition (1350 ml), and 25% from nursing (450 ml). The care plan further directed staff to provide R40 with his choice of fluids at each meal and place them at his bedside. The Physician's Order, dated 12/07/23, directed staff to implement a fluid restriction for R40 of 1800 ml every 24 hours. R40's Treatment Administration Record (TAR) for December 2023 lacked documentation the resident was on a fluid restriction. R40's TAR for January, February, March, and April 2024 lacked documentation the resident was on a fluid restriction. On 04/10/24 at 11:55 AM, observation revealed two 24-ounce (oz) mugs and a 20 oz disposable cup with coffee in it on R40's bedside table. On 04/10/24 at 12:35 PM, Certified Medication Aide (CMA) M stated she had not known R40 was on a fluid restriction even though the fluid restriction was displayed on the face sheet of the EMR in bold letters. CMA M further stated she also worked the floor as a Certified Nurse Aide (CNA) and was unaware of the restriction. On 04/10/24 at 12:45 PM, Licensed Nurse (LN) G stated she worked a couple of days a week and was unsure if R40 was on a fluid restriction or where staff would document fluid intakes. On 04/10/24 at 12:55 PM, Dietary BB stated she would be notified by her supervisor if a resident was on a fluid restriction and the supervisor would inform her how much fluid would be given at meals. Dietary BB stated she was unaware of R40's fluid restriction. On 04/15/24 at 02:14 PM, Administrative Nurse D verified R40's fluid restriction was never implemented by staff and said staff should have been monitoring R40's fluid intake. The facility's Fluid Restrictions and Additions policy, dated 09/22, documented that fluid restrictions were ordered by the physician, and dining services would adjust the resident's menu and nourishments accordingly. The amount of fluid for each item would be indicated on the resident's menu or tray ticket and nursing personnel were responsible for recording and monitoring the fluid intake. Dining services would provide 75% of the fluid restriction and nursing would provide 25% of the fluid restriction. The facility failed to establish a fluid restriction as ordered for R40. This placed the resident at risk for dehydration or fluid overload.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 55 residents. The sample included 14 residents, with seven reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment and failed to develop a comprehensive trauma-informed care plan for Resident (R) 35, who had a diagnosis of post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). This placed R35 at risk for unmet behavioral and mental health needs and retraumatization. Findings included: - The Electronic Medical Record (EMR) for R35 documented diagnoses of PTSD, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS), dated [DATE], documented R35 had intact cognition and required supervision with toileting, transfers, and bathing. R35 required set-up assistance with personal hygiene; R35 was independent with mobility. The assessment documented R35 received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medication and had no behaviors. R35's Care Plan, dated 01/08/24 and initiated 01/05/24, documented R35 received psychotropic (medication used to treat mental illnesses) medication with the potential for drug-related complications from anxiety and depression. The plan directed staff to educate the family on potential risks, benefits, and alternatives, administer medication as ordered, and monitor for adverse side effects. The care plan lacked direction to staff on R35's trauma triggers and coping strategies. R35's EMR lacked evidence a trauma-informed assessment was completed for R35 after admission. The Physician's Order, dated 12/27/23, directed staff to administer buspirone (an antianxiety medication), 5 milligrams (mg) by mouth twice per day for depression. The Physician's Order, dated 12/27/23, directed staff to administer Trazadone (an antidepressant medication), 50 mg by mouth at bedtime for depression. The Physician's Order, dated 01/08/24, directed staff to administer Lexapro (an antidepressant), 10 mg by mouth daily for depression. On 04/10/24 at 09:38 AM, observation revealed R35 at a group activity actively participating. On 04/10/24 at 12:20 PM, Certified Nurse Aide (CNA) R stated she had not been aware of R35's PTSD diagnosis and she was not informed of any triggers R35 would have or of her history. On 04/11/24 at 09:46 AM, Licensed Nurse (LN) G stated she had not been aware of R35's diagnosis of PTSD and did not know what her triggers were. LN G stated R35 was quiet and did not have any type of behavior. On 04/11/24 at 01:00 PM Social Services X stated she had completed a life stressor assessment on R35 when the resident was previously in the facility back in June 2023 but said she had not completed a trauma-informed care assessment for the most recent admission. Social Services X further stated she had not spoken with staff regarding R35's PTSD triggers due to R35's intact cognition and R35 was a very private person. Social Services X verified that she had not completed any care plan for R35 related to her mood and PTSD diagnosis. On 04/15/24 at 02:15 PM, Administrative Nurse D stated she had provided the staff with education related to R35's PTSD and stated a care plan was just completed to assist staff in recognizing what triggered R35's PTSD and anxiety. Administrative Nurse D said she was not aware R35 needed to have a trauma-informed care assessment. The facility's Trauma Informed Care policy, dated 10/12/21, documented the organization was committed to implementing trauma-informed approaches to the care provided and the organizational culture created for the residents of the community. The policy further documented a trauma-informed assessment would be completed within 72 hours of admission for initial screening of a history of trauma and it would determine if the resident had trauma-related symptoms. The assessment would be completed by Social Services, designee, or other licensed staff. The interdisciplinary team would discuss the findings to determine the resident's treatment plan including interventions to avoid re-traumatization and assist in identifying and managing trauma-related triggers. Staff would be trained and competency-tested on trauma-informed care during orientation, annually, and at any time deemed necessary by the supervisor. The facility failed to complete a trauma-informed care assessment and failed to develop a care plan for R35, who had a diagnosis of PTSD. This placed R35 at risk for unmet behavioral and mental health needs and retraumatization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 55 residents with 22 selected for review. Based on observation, interview and record review, the facility failed to review and revise the plan of care for one resident (R)2's with a pressure ulcer. Findings included: - Review of resident (R)2's Physician's Order Sheet, undated, revealed diagnoses included pneumonia (inflammation of the lungs), unspecified dementia (progressive mental disorder characterized by failing memory, confusion), restlessness with agitation, and localized edema (swelling). The admission MDS, dated 03/27/22, assessed the resident with moderate cognitive impairment, required extensive assistance of two persons with bed mobility, transfer, and ambulation. The resident had no impairment in range of motion in the upper or lower extremities, with no current pressure ulcers and was at risk for pressure ulcers development with no interventions in place. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment, required extensive assistance of two persons with bed mobility, transfer, and ambulation. The resident had no impairment in range of motion in the upper or lower extremities. The resident was assessed as at risk for pressure ulcer development and had no unhealed pressure ulcers. The resident had a pressure reducing devise on her bed. The Pressure Ulcer Care Area Assessment (CAA), dated 05/16/22, assessed the resident at risk for pressure ulcer and other related skin complications due to decreased mobility incontinence, self-care limitations and dementia. The resident had no current pressure related skin alterations. A Braden score (an assessment for pressure ulcer risk) of 18 indicated a risk for skin integrity concerns. The Quarterly MDS, dated 08/16/22, assessed the resident with severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfer and ambulation. The resident was at risk for developing pressure ulcers and had one unstageable pressure ulcer. The resident had a pressure reducing device for her bed and pressure ulcer care and application of dressings to her feet. The Care Plan, reviewed 07/11/22, instructed staff the resident was at risk for pressure ulcers and not able to make major position changes independently. The resident required extensive assistance with transfers and bed mobility. Staff to encourage adequate intake at meals and offer snacks. The resident took a diuretic (medication to remove excess fluid) for hypertension (high blood pressure). This care plan lacked interventions for the blood blister and subsequent pressure ulcer/wound on her left foot. A Wound Treatment Order dated 06/08/22, revealed the resident had an ulcer (described as other) on her left heel with measurements of 1.25 centimeters (cm) by 1 cm, by 0.25 in depth. The wound had no drainage. Staff requested wound cleanser with an autolytic (an agent that breaks down damaged tissue) agent for debridement (removal of damaged tissue) and to change the dressing every 3-5 days. The physician signed the request, and the treatment began on 06/11/22, per review of the June 2022 treatment administration record (TAR). A Physician's Order, dated 07/03/22, instructed staff to keep pressure off the left heel and float it with a pillow three times a day, per the July 2022 TAR. An e-mail, dated 08/19/22, Licensed Nursing staff (LN) H, described the resident's left foot ulcer as 0.5 by 0.5 by 0.3 with 0.4 cm tunneling, and requested an order to apply calcium alginate (a type of material that minimize infection and form a moist gel) to the wound bed. Per the August 2022 TAR this treatment started 08/20/22. A Nursing Progress Note, dated 03/21/22, assessed the resident with 2-3 plus pitting edema in her lower extremities. Staff identified a scabbed area to her left elbow and pink discoloration to her coccyx region. A Nursing Progress Note, dated 04/14/22, indicated the resident had intermittent confusion and forgetfulness but was alert and oriented and worked with therapy. The resident had bilateral dependent edema and had lymphedema wraps applied by therapy to her bilateral lower legs. A Nursing Progress Note, dated 05/05/22, indicated the resident was admitted to hospice care. The Braden scores for pressure ulcer development documented as follows: On 03/24/22, score of 17 (19-23 no risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, 6-9 very high risk). On 04/07/22, score of 16 mild risk. On 06/23/22, score of 18 mild risk. The Skin Evaluation Record General Skin Check dated 05/11/22 at 07:20 AM, indicated the resident had no new issues. The Skin Evaluation Record General Skin Check, dated 05/11/22 at 09:19 AM, indicated the resident had a blood blister on her left heel, approximately 2 centimeters (CM) by 1 centimeter with undefined edges and without pain. Review of the May 2022, treatment administration record, lacked documentation of daily monitoring of the blood blister. The medical record lacked documentation of daily monitoring or resolution of this blood blister. The Skin Evaluation Record General Skin Check, dated 05/18/22 at 06:54 AM, revealed the resident had no existing issues. The Skin Evaluation Record General Skin Check, dated 05/25/22 at 02:21 PM, indicated the resident had no existing issues. The Skin Evaluation Record General Skin Check, dated 06/01/22 at 08:57 AM, indicated the resident had no new issues. The Skin Evaluation Record Left Heel dated 06/18/22, indicated the resident had a partial thickness wound on her left heel, measuring 1.5 cm by 1.5 cm with a depth of 0.1 cm with origin date of 06/11/22. Staff cleansed the wound with wound spray and applied a foam dressing. The Skin Evaluation Record General Skin Check, dated 06/22/22 indicated no new issues. The Skin Evaluation Record Left Heel dated 06/28/22, indicated the resident had a partial thickness wound to her left heel measured 0.9 by 0.8 by 0.1 cm with irregular edges with dry yellow scab in place surrounded by new epithelial tissue. Staff cleansed the wound with wound spray and applied a foam dressing. The Skin Evaluation Record Left Heel, dated 07/03/22, indicated the resident had a small circular lesion, painful to touch, with 60% clean non-granulating tissue, and 40 % slough with an increase in the wound from the prior week with measurements of 1.5 cm by 1 cm by 0.2 cm with scant serous (yellow clear fluid) drainage. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/11/22, reveals a circular lesion with 100% slough. A soft debridement used but painful to fully remove the slough layer. The area measured 0.8 by 0.6 by 0.1 cm. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/16/22, revealed a circular lesion with 100% slough with measurements of 0.7 by 0.6 by 0.1 cm. Staff debrided the wound and revealed granulating tissue with pink epithelial tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/29/22, revealed 100% slough with measurement of 0.7 by 0.6 by 0.1 cm. Staff debrided the wound, and revealed granulating tissue and pink epithelial tissue surrounding the wound edge. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/05/22, revealed the wound measurement of 0.5 by 0.7 by 0.2 with macerated wound edge and pink tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/09/22, revealed the 0.7 by 0/9 by 0.2 cm with macerated surrounding tissue and a pink tissue surrounding the wound. The Skin Evaluation Record Left Heel, dated 08/18/22, revealed the wound measured 0.5 by 0.5 by 0.3 cm with undermining of 0.4 cm at 2:00 o'clock, macerated wound edge and pink tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/24/22, revealed staff applied calcium alginate to the wound bed and covered it with a foam dressing. The wound had a scant amount of purulent drainage on the dressing with slough noted to the wound bed. Staff measured the wound as 0.2 by 0.3 cm with no depth and discoloration noted in the surrounding skin. Observation, on 08/23/22 at 09:15 AM, revealed the resident seated in her recliner with footrest elevated. The resident had her shoes on, and her feet were hanging off the end of the footrest beginning at her lower ankle area and continued in this manner until 10:00 AM. Observation on 08/23/22 at 10:00 AM, with Licensed Nurse (LN) G, revealed she did notice a blood blister in the area in May, but it did not currently require treatment and the staff performs weekly skin assessments. LN G stated she did not know how this ulcer developed, but since she was on hospice services, wound care was not consulted. LN G stated nursing staff check the dressing daily, and change the dressing as needed but at least every 3 days. LN G removed the resident's shoe and the dressing to her left heel was intact. LN G then replaced the resident's shoe after asking the resident if she wanted her shoe on. The resident sat in her recliner with the footrest in the elevated position and her heel positioned off the end of the footrest. LN G stated the resident preferred to keep her shoes on when in her recliner, but the heel was off the edge of the footrest for pressure relief. Interview, on 08/23/22 at 02:45 PM, with Certified Nurse Aide (CNA) O, revealed the resident sits in her recliner with the footrest elevated but prefers to keep her shoes on. CNA O stated the resident ambulates with her walker with stand by assistance of staff. Observation on 08/24/22 at 08:44 AM, with LN H, revealed she does wound care once a week and measures the area. At that time LN H removed the resident's shoe and sock and observed the wound on the left lateral heel area. LN H measured the wound as 0.2 cm by 0.3 cm with no depth. The wound was yellow brown in color. LN H stated the wound had tunneling last week but greatly improved. LN O did not know if staff float her heels but thought they did when she lay in bed LN H did not know if staff removed her shoes when she sat in the recliner. LN H stated the resident no longer received wraps for lymphedema (accumulation of fluid) but did not know when therapy stopped the wraps. Interview, on 08/24/22 at 03:30 PM, with LN I, revealed the resident sits in her recliner with her shoes on per her preference. She stated staff float her heels at night in bed with pillows. Interview, on 08/24/22 at 10:57 AM, with Administrative Nurse DD, confirmed the care plan lacked interventions for the resident's left foot pressure ulcer and would expect nursing staff to add interventions as needed to heal and prevent further decline. Interview, on 08/24/22 at 04:30 PM, with Administrative Nurse D, revealed she would expect staff to update the care plan to include interventions for the blood blister and subsequent pressure ulcer on the resident's left foot. Administrative Nurse D stated she would expect nursing staff to identify risk factors and revise the care plan as indicated. The facility policy Skin Integrity: Pressure Ulcer/Injury Prevention, Nursing Intervention and Wound Treatment, revised 10/21/21, instructed staff to provide daily documentation of heel pressure ulcer/injury. Risk factors should be reviewed along with possible causes and a determination made to what extents if any, the factors can be modified. Modifiable risk factors should be addressed in the plan of care. The facility failed to review and revise this resident's care plan for specific interventions and risk factors for her left heel pressure ulcer to heal and prevent further decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 55 residents with 22 selected for review which included two residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure staff provided care and interventions to prevent pressure ulcers for one of two sampled at risk residents (R)2 in which staff identified a blood blister on her foot and subsequently developed an unstageable pressure ulcer (coverage of a wound by slough and/or eschar) on the same area of the foot. Findings included: - Review of resident (R)2's Physician's Order Sheet, undated, revealed diagnoses included pneumonia (inflammation of the lungs), unspecified dementia (progressive mental disorder characterized by failing memory, confusion), restlessness with agitation, and localized edema (swelling). The admission MDS, dated 03/27/22, assessed the resident with moderate cognitive impairment, required extensive assistance of two persons with bed mobility, transfer, and ambulation. The resident had no impairment in range of motion in the upper or lower extremities, with no current pressure ulcers and was at risk for pressure ulcers development with no interventions in place. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment, required extensive assistance of two persons with bed mobility, transfer, and ambulation. The resident had no impairment in range of motion in the upper or lower extremities. The resident was assessed as at risk for pressure ulcer development and had no unhealed pressure ulcers. The resident had a pressure reducing devise on her bed. The Pressure Ulcer Care Area Assessment (CAA), dated 05/16/22, assessed the resident at risk for pressure ulcer and other related skin complications due to decreased mobility incontinence, self-care limitations and dementia. The resident had no current pressure related skin alterations. A Braden score (an assessment for pressure ulcer risk) of 18 indicated a risk for skin integrity concerns. The Quarterly MDS, dated 08/16/22, assessed the resident with severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfer and ambulation. The resident was at risk for developing pressure ulcers and had one unstageable pressure ulcer. The resident had a pressure reducing device for her bed and pressure ulcer care and application of dressings to her feet. The Care Plan, reviewed 07/11/22, instructed staff the resident was at risk for pressure ulcers and not able to make major position changes independently. The resident required extensive assistance with transfers and bed mobility. Staff to encourage adequate intake at meals and offer snacks. The resident took a diuretic (medication to remove excess fluid) for hypertension (high blood pressure). A Wound Treatment Order dated 06/08/22, revealed the resident had an ulcer (described as other) on her left heel with measurements of 1.25 centimeters (cm) by 1 cm, by 0.25 in depth. The wound had no drainage. Staff requested wound cleanser with an autolytic (an agent that breaks down damaged tissue) agent for debridement (removal of damaged tissue) and to change the dressing every 3-5 days. The physician signed the request, and the treatment began on 06/11/22, per review of the June 2022 treatment administration record (TAR). A Physician's Order, dated 07/03/22, instructed staff to keep pressure off the left heel and float it with a pillow three times a day, per the July 2022 TAR. An e-mail, dated 08/19/22, Licensed Nursing staff (LN) H, described the resident's left foot ulcer as 0.5 by 0.5 by 0.3 with 0.4 cm tunneling, and requested an order to apply calcium alginate (a type of material that minimize infection and form a moist gel) to the wound bed. Per the August 2022 TAR this treatment started 08/20/22. A Nursing Progress Note, dated 03/21/22, assessed the resident with 2-3 plus pitting edema in her lower extremities. Staff identified a scabbed area to her left elbow and pink discoloration to her coccyx region. A Nursing Progress Note, dated 04/14/22, indicated the resident had intermittent confusion and forgetfulness but was alert and oriented and worked with therapy. The resident had bilateral dependent edema and had lymphedema wraps applied by therapy to her bilateral lower legs. A Nursing Progress Note, dated 05/05/22, indicated the resident was admitted to hospice care. The Braden scores for pressure ulcer development documented as follows: On 03/24/22, score of 17 (19-23 no risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, 6-9 very high risk). On 04/07/22, score of 16 mild risk. On 06/23/22, score of 18 mild risk. The Skin Evaluation Record General Skin Check dated 05/11/22 at 07:20 AM, indicated the resident had no new issues. The Skin Evaluation Record General Skin Check, dated 05/11/22 at 09:19 AM, indicated the resident had a blood blister on her left heel, approximately 2 centimeters (CM) by 1 centimeter with undefined edges and without pain. Review of the May 2022, treatment administration record, lacked documentation of daily monitoring of the blood blister. The medical record lacked documentation of daily monitoring or resolution of this blood blister. The Skin Evaluation Record General Skin Check, dated 05/18/22 at 06:54 AM, revealed the resident had no existing issues. The Skin Evaluation Record General Skin Check, dated 05/25/22 at 02:21 PM, indicated the resident had no existing issues. The Skin Evaluation Record General Skin Check, dated 06/01/22 at 08:57 AM, indicated the resident had no new issues. The Skin Evaluation Record Left Heel dated 06/18/22, indicated the resident had a partial thickness wound on her left heel, measuring 1.5 cm by 1.5 cm with a depth of 0.1 cm with origin date of 06/11/22. Staff cleansed the wound with wound spray and applied a foam dressing. The Skin Evaluation Record General Skin Check, dated 06/22/22 indicated no new issues. The Skin Evaluation Record Left Heel dated 06/28/22, indicated the resident had a partial thickness wound to her left heel measured 0.9 by 0.8 by 0.1 cm with irregular edges with dry yellow scab in place surrounded by new epithelial tissue. Staff cleansed the wound with wound spray and applied a foam dressing. The Skin Evaluation Record Left Heel, dated 07/03/22, indicated the resident had a small circular lesion, painful to touch, with 60% clean non-granulating tissue, and 40 % slough with an increase in the wound from the prior week with measurements of 1.5 cm by 1 cm by 0.2 cm with scant serous (yellow clear fluid) drainage. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/11/22, reveals a circular lesion with 100% slough. A soft debridement used but painful to fully remove the slough layer. The area measured 0.8 by 0.6 by 0.1 cm. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/16/22, revealed a circular lesion with 100% slough with measurements of 0.7 by 0.6 by 0.1 cm. Staff debrided the wound and revealed granulating tissue with pink epithelial tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 07/29/22, revealed 100% slough with measurement of 0.7 by 0.6 by 0.1 cm. Staff debrided the wound, and revealed granulating tissue and pink epithelial tissue surrounding the wound edge. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/05/22, revealed the wound measurement of 0.5 by 0.7 by 0.2 with macerated wound edge and pink tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/09/22, revealed the 0.7 by 0/9 by 0.2 cm with macerated surrounding tissue and a pink tissue surrounding the wound. The Skin Evaluation Record Left Heel, dated 08/18/22, revealed the wound measured 0.5 by 0.5 by 0.3 cm with undermining of 0.4 cm at 2:00 o'clock, macerated wound edge and pink tissue surrounding the wound. Staff cleansed the wound with wound spray, applied a foam dressing and floated the heel. The Skin Evaluation Record Left Heel, dated 08/24/22, revealed staff applied calcium alginate to the wound bed and covered it with a foam dressing. The wound had a scant amount of purulent drainage on the dressing with slough noted to the wound bed. Staff measured the wound as 0.2 by 0.3 cm with no depth and discoloration noted in the surrounding skin. Observation, on 08/23/22 at 09:15 AM, revealed the resident seated in her recliner with footrest elevated. The resident had her shoes on, and her feet were hanging off the end of the footrest beginning at her lower ankle area and continued in this manner until 10:00 AM. Observation on 08/23/22 at 10:00 AM, with Licensed Nurse (LN) G, revealed she did notice a blood blister in the area in May, but it did not currently require treatment and the staff performs weekly skin assessments. LN G stated she did not know how this ulcer developed, but since she was on hospice services, wound care was not consulted. LN G stated nursing staff check the dressing daily, and change the dressing as needed but at least every 3 days. LN G removed the resident's shoe and the dressing to her left heel was intact. LN G then replaced the resident's shoe after asking the resident if she wanted her shoe on. The resident sat in her recliner with the footrest in the elevated position and her heel positioned off the end of the footrest. LN G stated the resident preferred to keep her shoes on when in her recliner, but the heel was off the edge of the footrest for pressure relief. Observation, on 08/23/22 at 11:30 AM, revealed staff ambulated with the resident and her walker to the dining room. Interview, on 08/23/22 at 02:45 PM, with Certified Nurse Aide (CNA) O, revealed the resident sits in her recliner with the footrest elevated but prefers to keep her shoes on. CNA O stated the resident ambulates with her walker with stand by assistance of staff. Observation on 08/24/22 at 08:44 AM, with LN H, revealed she does wound care once a week and measures the area. At that time LN H removed the resident's shoe and sock and observed the wound on the left lateral heel area. LN H measured the wound as 0.2 cm by 0.3 cm with no depth. The wound was yellow brown in color. LN H stated the wound had tunneling last week but greatly improved. LN O did not know if staff float her heels but thought they did when she lay in bed LN H did not know if staff removed her shoes when she sat in the recliner. LN H stated the resident no longer received wraps for lymphedema (accumulation of fluid) but did not know when therapy stopped the wraps. Interview, on 08/24/22 at 03:30 PM, with LN I, revealed the resident sits in her recliner with her shoes on per her preference. She stated staff float her heels at night in bed with pillows. Interview, on 08/24/22 at 04:30 PM, with Administrative Nurse D, revealed she would expect staff to follow the wound protocol and monitor the blood blister when identified on 05/11/22. Administrative Nurse D stated she would expect nursing staff to identify risk factors and revise the care plan as indicated. The facility policy Skin Integrity: Pressure Ulcer/Injury Prevention, Nursing Intervention and Wound Treatment, revised 10/21/21, instructed staff to provide daily documentation of heel pressure ulcer/injury. The licensed nurse will complete a skin evaluation and if new alterations are noted the licensed nurse will initiate treatment per guidelines and document as indicated. The support surface is on aspect of the comprehensive treatment plan. Utilizing a therapeutic support surface does not lessen the need to turn the resident, utilize clinically proven treatment regimes, provide nutritional support or routinely assess the wound. Staff instructed to use site specific support surfaces on the resident's extremities. Risk factors should be reviewed along with possible causes and a determination made to what extents if any, the factors can be modified. Modifiable risk factors should be addressed in the plan of care. The facility failed to monitor daily for resolution of this resident's blood blister identified on 05/11/22, failed to identify causative factors of the development of the blister and failed to timely determine interventions for the prevention of pressure ulcer injury which resulted in an unstageable pressure injury to the resident's heel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 55 residents with 22 selected for review including six residents reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to follow and implement care plan interventions following a fall for Resident (R)7 and failed to ensure the oxygen tubing for R14 was off the floor to reduce a tripping hazard. Findings included: - The Physician Orders for 08/22/22, for Resident (R)7 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and history of falling. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R7 with a short-term and a long-term memory problem and moderately impaired decision making. He required extensive assistance of one staff for transfers and limited assistance of one for walking. His balance during transitions were not steady and required staff to support him, however he could balance himself when walking. R7 used a walker for mobility and had not had any falls since the prior assessment. The Significant Change MDS dated 05/25/22 did not reveal any changes to his cognition, transfers, or walking. His balance during transitions and walking were not steady and required staff support. He continued to use a walker for mobility and since the last assessment he had one non-injury fall and had one fall with injury that was not a major injury (break in a bone, head injury). The Falls Care Area Assessment dated 05/30/22 revealed R7's fall risk score was 18, indicating a high risk for falls, and he has had several falls due to his poor balance and unsteady gait. The Care Plan dated 05/08/22 for R7 revealed he was at risk for falls due to his confusion, multiple medications, history of falls and general weakness. Interventions included for the staff to ensure his bed was in the position easiest for him to access/exit, assist with ambulation when he was feeling weak or having poor balance, and to remind him to use the walker as sometimes he forgot. R7 required a walker and limited to extensive assist of staff with walking. The care plan had these added interventions: 1. On 08/01/22, the staff were to keep his walker within his reach but not directly in front of him when he was in his room. 2. On 08/22/22, the staff were to increase visual checks to approximately every hour when he was in his room, and to maximize his independence and quality of life by adding an easy touch call light. The Interdisciplinary Notes (ID) located in the electronic medical record (EMR) revealed R7 fell on [DATE], 04/29/22, 05/08/22, and 08/21/22. The ID note located in the EMR, dated 08/22/22 at 12:41 AM, revealed the staff found R7 sitting on the floor in the middle of the room on 08/21/22 at 11:30 PM. R7 stated he was walking across the room and going back to bed. The fall resulted in an abrasion (scraping or rubbing away of a surface, such as skin, by friction) to the left buttocks 14.4 centimeters (cm) by 3.7 cm and an abrasion to the right side of his back measuring 17.1 cm by 1.4 cm. The intervention was to increase visual checks to approximately every hour when he was in his room. The facility Investigation Report for the fall on 08/21/22 included additional interventions of an easy touch call light pad placed in R7's room on 08/22/22 and to keep his walker within reach but not directly in front of him when he was in his room. On 08/23/22 01:34 PM, R7 was in his room sitting in the recliner and his walker was across the room at the foot of the bed out of his reach. The staff failed to ensure the walker was in reach while in his room as planned to prevent further falls. On 08/23/22 at 02:55 PM, R7 continued to sit in his room in the recliner with the walker out of reach. The staff failed to ensure the walker was in reach while he was in his room. On 08/24/22 at 08:51 AM, Certified Medication Aide (CMA) LL, who was providing direct care, stated R7 was a fall risk and there was a touch pad call light that the staff placed beside him. CMA LL stated when he was in his room the walker was to be in his reach in front of him and she had not been told what the new fall intervention was for his fall on 08/21/22. CMA LL stated there was not a place to look and see what the intervention was, the charge nurse would let her know. On 08/24/22 at 08:58 AM, CMA T, who was providing direct care, stated R7 was a fall risk and was told on 08/22/22 that he fell but she did not know what the new intervention was put in place to prevent further falls. CMA T stated he did have a touch pad call light that was beside him and the staff check on him about every 15 minutes and the new intervention was probably in the care plan book. On 08/24/22 at 03:25 PM, observed R7 in his room sitting in his recliner and the touch pad call light was draped across the top of a folding tray table next to the recliner, rather than placed next to him. On 08/24/22 at 03:29 PM, CNA MM stated when she comes in for her shift, report was done and that was when any new fall interventions were communicated. CNA MM stated typically a new intervention was not put in place after a fall unless it keeps happening then they would come up with a new intervention to prevent a fall from happening again. CNA MM was not sure if R7 was a fall risk as it was her second time working that unit and did not know if R7 had fell recently, however stated the touch pad call light should be placed on his chair. CNA MM was not aware of any other interventions other than lowering the bed to the floor. On 08/24/22 at 03:47 PM, Licensed Nurse (LN) I stated when a resident falls the staff attempt to determine the cause of the fall, come up with a new intervention to prevent further falls, and document the intervention on the care plan and in the ID notes. The staff were made aware of the intervention by passing it on in report and the intervention was in the care plan. The care plan included an intervention on 08/22/22 for an easy touch call light and to keep the walker in his reach but not directly in front of him when in his room. LN I stated she would expect the staff to follow the care plan. On 08/25/22 at 11:45 AM, Administrative Nurse D stated she expected the staff to communicate fall interventions during shift-to-shift report, place the intervention on the care plan which all staff had access to, and staff should follow the care plan interventions. The facility policy Falls dated 10/11/21 included interventions after a fall should be documented on the care plan, however lacked direction how to communicate if a fall occurred and the post fall interventions to the staff. The facility failed to follow the implemented interventions following R7's fall, failed to communicate the interventions to the staff, for R7 with a history of falls, to prevent further falls. Review of resident (R)14's Physician Order Sheet, undated, revealed diagnoses included cerebral infarction (stroke sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), Chronic Obstructive Pulmonary Disease (COPD progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dementia (progressive mental disorder) characterized by failing memory, confusion, and rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with moderate cognitive impairment, required limited assistance of one person for bed mobility, transfer toilet use, dressing and personal hygiene. The resident required supervision with ambulation and had unsteady balance with stabilization with staff assistance. The resident had no impairment in the upper or lower extremities. The resident was not on a toileting plan and had occasionally urinary incontinence and frequent bowel incontinence. The Fall Care Area Assessment (CAA,) dated 06/14/22, assessed the resident had impaired balance with contributing factors of weakness and physical performance limitations affecting balance and history of falls. The 'Urinary Incontinence CAA dated 06/14/22, assessed the resident required assistance with toileting and had occasional urinary incontinence. The Care Plan, reviewed 08/18/22, instructed staff the resident sometimes moved too fast with a walker and staff were to remind her to slow down. Staff instructed to remind the resident to sit farther back in her chair and bed to help prevent falls. Staff instructed to offer to walk with the resident when she was having balance problems. Staff to remind the resident to check the wheels on her walker before she starts ambulating. Staff instructed to check on her often and offer to take her to the bathroom. Staff to provide the resident with the shortest length of oxygen tubing appropriate for her needs so she does not trip on it. Staff to make sure her walker is within her reach. Review of the Fall Investigation Report, dated 07/17/22 at 08:00 PM, revealed staff found the resident on the floor in her room and the resident stated she tripped over her oxygen tubing. The immediate intervention was to remind the resident to manage her oxygen tubing and to change her concentrator to her portable unit which was attached to her walker. Observation, on 08/22/22 at 03:02 PM, revealed the resident in bed without her oxygen on. The resident's oxygen concentrator was on and the tubing was in a disorganized pile on the floor beside the oxygen concentrator which was positioned beside the resident's bed. The resident's portable oxygen concentrator was on her walker near her chair, with the tubing also on the floor. Interview, on 08/22/22 at 03:15 PM, with Certified Nurse Aide (CNA) P, revealed the resident will often put herself in bed and forget to wear the oxygen. CNA P stated the portable oxygen concentrator needs to be recharged when not in use. CNA P stated the resident's tubing was extra long so she could go the bathroom with it. Observation, on 08/23/22 at 12:46 PM, revealed CNA Q, assisted the resident to her room with the rolling walker and portable oxygen. CNA Q did not offer the resident a toileting opportunity and positioned the resident in her bed and placed the nasal cannula from the room oxygen concentrator on the resident. The tubing was in a disorganized pile on the floor beside the oxygen concentrator beside her bed. Observation, on 08/23/22 at 12:51 PM, revealed the resident got herself up out of bed and ambulated to the bathroom in her room. CNA Q stated the resident does get up by herself and confirmed the resident could trip over the oxygen tubing that was laying on the floor. Interview, on 08/24/22 at 12:11 PM, with Licensed Nurse (LN) I, revealed she would expect staff to keep the oxygen tubing off the floor and in a plastic bag attached to the oxygen concentrator. LN I stated the resident often took herself to the bathroom, so her tubing was longer than average to enable her to keep it on when in the bathroom. LN I confirmed the tubing could be a trip hazard and staff needed to keep it in a neat coil. Staff should toilet the resident upon return to her room and before/after meals. Interview, on 08/24/22 at 04:30 PM, with Administrative Nurse D, revealed she expected staff to keep the oxygen tubing in a manner to prevent falls. Administrative Nurse D stated the oxygen tubing was exceptionally long and the facility needed to find ways to limit the trip hazard. The facility policy Falls, revised 10/11/21, instructed staff to identify residents for risk of falls and implement interventions to reduce the resident of falls. The facility failed to implement measures to reduce the risk of further falls for this resident with extra long oxygen tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 55 residents with 22 selected for review including 12 residents reviewed for unnecessary medications. Based on record review and interview, the facility failed to act upon the pharmacy recommendation for one of the residents, Resident (R)20. Findings included: - The diagnosis tab, located at the dashboard in the electronic medical record (EMR), for Resident (R)20, included a diagnosis of hypertension (elevated blood pressure). The Medication Record for 08/2022, included a physician order with a start date of 03/07/22, for instructions to administer the resident Metoprolol tartrate (medication used to treat hypertension), 50 milligrams (mg), by mouth, twice daily for hypertension. The Interdisciplinary Note (ID) note, dated 05/31/22, revealed the consultant pharmacist reviewed the resident's available chart data and instructed the staff to refer to the recommendation. The Note to Attending Physician/Prescriber with a print date of 05/31/22, revealed R20 was [AGE] years old and has had several low blood pressures and variable pulses. Please take a moment to review blood pressure and pulse data and consider if medication reduction(s) were appropriate currently, or, provide a statement below acknowledging review and desire to continue present therapy. The form included a physician signature, lacked a date when the physician signed, and lacked a response to agree, disagree, or statement acknowledging review and desire to continue the present therapy. Handwritten on the form included noted 06/03/22 by Licensed Nurse (LN) I. The facility failed to act upon the pharmacist recommendation to ensure the physician responded to address if a medication reduction was appropriate. The Progress Note for the physician visit dated 07/07/22, revealed under the assessment section hypertension-overmedicated. The progress note included an order to decrease Metoprolol to 25 mg, by mouth, twice daily. On 08/25/22 at 08:41 AM, LN J stated when there are recommendations from the pharmacy reviews, the staff fax the recommendation to the doctor. If the physician declines the recommendation, we document that in an ID note, and if they agree with the recommendation, we document that in an ID note and what the new order was, then the order would be added to the EMR. LN J stated if the physician signs the recommendation, but does not include a response, she would then call the physician and add the clarification or refax the note and place it in the report book until the response received. On 08/25/22 at 09:41 AM, Administrative Nurse F stated she sends the pharmacy recommendations to the physician, and they are returned via the electronic fax system program to her fax number. Administrative Nurse F stated if the physician signs the pharmacy recommendation form but does not answer a response, the recommendation form should be sent back to the physician. The recommendation printed on 05/31/22 regarding R20's low blood pressures should have been sent back to the physician for a response. The facility did not provide a policy for processing pharmacy reviews. The facility failed to act upon the pharmacist recommendation to ensure the physician responded to the pharmacy consultant recommendation for R20 on 05/31/22 timely. R20 continued with low blood pressures and the physician addressed the low blood pressures on a visit on 07/07/22, with new orders to decrease the medication for hypertension, 37 days after the pharmacy recommendation.

The facility reported a census of 55 residents with 22 residents selected for review including 12 residents reviewed for unnecessary medications. Based on record review and interview the facility failed to provide adequate monitoring for Lasix, Potassium, and Metoprolol medications for one of the sampled residents, Resident (R)20, to ensure no unnecessary medication usage. Findings included: - The diagnosis tab, located at the dashboard in the electronic medical record (EMR), for Resident (R)20, included diagnoses of hypertension (elevated blood pressure), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and pulmonary edema (accumulation of extravascular fluid in the lung tissues). The physician orders, located in the EMR included the following: 1. Lasix (diuretic medication used to treat fluid build-up) 40 milligrams (mg), twice daily, by mouth, for edema, on 05/17/22. 2. Potassium chloride (electrolyte replacement that Lasix excretes from the body), 20 milliequivalents (mEq), twice daily, by mouth, for hypokalemia (low potassium level). 3. Metoprolol tartrate (medication used to treat hypertension), 25 mg, by mouth, twice daily, for hypertension, on 08/05/22. The Progress Note for the physician visit dated 07/07/22, revealed under the assessment section hypertension-overmedicated. The progress note included an order to decrease Metoprolol to 25 mg, by mouth, twice daily. The note included a fax date of 07/08/22. Additionally, on 07/07/22, the physician ordered laboratory testing to monitor the resident's Lasix, Potassium and Metoprolol with consider CBC (completed blood count-blood test that provides information about the cells in a person's blood), BMP (basic metabolic profile-blood test that measures eight different substances in the blood), and BNP (brain natriuretic peptide-blood test measures levels of a protein in the blood to provide information on how the heart is working). The physician order tab, located under the attachment link in the EMR, revealed the staff scanned in the physician visit progress note dated 07/07/22, on 07/22/22 (15 days after the physician order). The Interdisciplinary Note (ID) dated 08/05/22, for R20 revealed a Certified Medication Aide (CMA) reported to the charge nurse R20's blood pressure was low this evening, reading 98/54. The charge nurse reviewed the record and found the Metoprolol had parameters for a pulse of less than 50 but no parameters for the blood pressure. Upon reviewing the EMR the nurse located an order dated 07/07/22 (over a month prior), on a progress note to decrease the Metoprolol to 25 mg, by mouth, twice daily and the ID notes lacked any physician order changes. The staff notified the physician on call, which gave orders to start Metoprolol, 25 mg, by mouth, twice daily and to obtain labs: CBC, BMP, and BNP. On 08/25/22 at 08:41 AM, Licensed Nurse (LN) J stated R20's physician faxes her progress notes, which will include order changes, two to three days after her visit to the facility. The faxes are received through the electronic fax system, which required a staff to have an email address to access the fax system. When a new progress note comes through an email arrives to the nursing staff, director of nursing, quality assurance nurse, medical records, and assistant director of nursing, and a nurse from the assisted living side. We then have a Physician Order Flow Sheet that was to be filled out with new physician orders and then attach the printed order to the flowsheet and place in the file box for medical records. The orders were to be noted when processed. LN J stated the flow sheet had been in place for one to two months. On 08/25/22 at 11:40 AM, Administrative Nurse D stated the orders received on 07/08/22 and scanned in on 07/22/22 were not processed and should have been. Some of the agency nurses did not have access to the system as that company did not want them to have access and we had to ask for special permission for them to get access for the frequently working agency nurses. The Physician Order Flow Sheet undated, included for all orders to enter the order in the Physician Orders and document the details of the order (name of medication, dose, diagnosis, treatment location, notification of DPOA (Durable Power of Attorney) and the order sent to the pharmacy. The staff were to pull up the medication record/treatment record to ensure the order displayed correctly. The facility failed to adequately monitor the resident's Lasix, Potassium and Metoprolol medications use to ensure no unnecessary medication usage or adverse reactions.

- The diagnosis tab, located at the dashboard in the electronic medical record (EMR), for Resident (R)20, included diagnoses of hypertension (elevated blood pressure), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and chronic pain. The Medication Record for 08/2022, included these physician orders: 1. On 01/19/22, Lidocaine (medication used to relieve pain) pain relief, four percent topical patch, once daily, for low back pain. 2. On 03/07/22, Metoprolol tartrate (medication used to treat hypertension), 50 milligrams (mg), by mouth, twice daily for hypertension. 3. On 06/28/22, hydrocodone-acetaminophen (medication used to treat pain), 7.5 mg/325 mg, by mouth, three times daily, for pain. The Progress Note for the physician visit dated 07/07/22, revealed under the assessment section hypertension-overmedicated. The progress note included an order to decrease Metoprolol to 25 mg, by mouth, twice daily. The note included a fax date of 07/08/22. Additional orders included: 1. Peri-cream, to rectal area, as needed. 2. Biofreeze (medication used to treat pain), to right hand/elbow/forearm, twice daily as needed. 3. Chest x-ray. 4. Consider CBC (completed blood count-blood test that provides information about the cells in a person's blood), BMP (basic metabolic profile-blood test that measures eight different substances in the blood), and BNP (brain natriuretic peptide-blood test measures levels of a protein in the blood to provide information on how the heart is working). 5. Anusol (medication used to treat irritation/itch/swelling of hemorrhoids) cream, to the rectal area, twice daily. The physician order tab, located under the attachment link in the EMR, revealed the staff scanned in the physician visit progress note dated 07/07/22, on 07/22/22 (15 days after the physician order). The Interdisciplinary Note (ID) dated 08/05/22, for R20 revealed a Certified Medication Aide (CMA) reported to the charge nurse R20's blood pressure was low this evening, reading 98/54. The charge nurse reviewed the record and found the Metoprolol had parameters for a pulse of less than 50 but no parameters for the blood pressure. Upon reviewing the EMR the nurse located an order dated 07/07/22 (over a month prior), on a progress note to decrease the Metoprolol to 25 mg, by mouth, twice daily and the ID notes lacked any physician order changes. The staff notified the physician on call, which gave orders to: 1. Start Metoprolol, 25 mg, by mouth, twice daily. 2. Obtain labs: CBC, BMP, and BNP. 3. Discontinue the Anusol cream. 4. Discontinue the chest x-ray. 5. Start Biofreeze, to right hand/elbow/forearm, twice daily, as needed. The Medication Record dated 08/2022, for the Lidocaine patch, revealed the staff did not administer the medication due to med not available. The ID note dated 08/10/22 at 03:17 PM\, revealed R20 was to have a Lidocaine patch placed every morning and removed every evening. It was discovered during medication pass on 08/09/22, that R20 did not have a Lidocaine patch placed. The facility investigation notes, for 08/09/22, revealed the evening CMA went to remove the patch per the Medication Record and R20 lacked a patch. The Medication Record dated 08/14/22, included that on 08/14/22, the staff administered hydrocodone-acetaminophen for the scheduled time of 07:00 PM through 10:00 PM. The Individual Residents Controlled Substance Record for R20 for the hydrocodone-acetaminophen, for the bedtime dose, lacked an entry for 08/14/22. The count was correct indicating the staff did not administer the medication. The ID note dated 08/18/22 at 11:16 AM, revealed the staff notified R20's responsible party of a medication error with the hydrocodone/acetaminophen at bedtime on 08/14/22. On 08/25/22 at 08:41 AM, Licensed Nurse (LN) J stated R20's physician faxes her progress notes, which will include order changes, two to three days after her visit to the facility. The faxes are received through the electronic fax system, which required a staff to have an email address to access the fax system. When a new progress note comes through an email arrives to the nursing staff, director of nursing, quality assurance nurse, medical records, and assistant director of nursing, and a nurse from the assisted living side. We then have a Physician Order Flow Sheet that was to be filled out with new physician orders and then attach the printed order to the flowsheet and place in the file box for medical records. The orders were to be noted when processed. LN J stated the flow sheet had been in place for one to two months. On 08/25/22 at 09:41 AM, interview with Administrative Nurse E and Administrative Nurse F revealed the Physician Order Flow Sheet had been in place for years. The physician progress notes which can include orders comes to the electronic fax system, and they arrive all together from all three halls, any nurse can see the notes. An agency nurse may not have an email to be able to get into the system and there was not always a facility nurse on duty each shift to access the system. When an order comes through, the nurse should print work the order following the Physician Order Flow Sheet, make a note in the ID notes of the EMR, place the order with the flow sheet in the medical records box, then medical records checks to see if the nurse entered the order correctly into the EMR. The orders scanned in the EMR on 07/22/22, were not entered into the EMR system for the staff to follow. The CMA working on 08/14/22, signed she gave the medication in the EMR, but not on the controlled substance record. The staff were unable to find the Lidocaine patch due to it being removed on 08/08/22. On 08/25/22 at 11:40 AM, Administrative Nurse D stated the orders received on 07/08/22 and scanned in on 07/22/22 were not processed and should have been. Some of the agency nurses did not have access to the system as that company did not want them to have access and we had to ask for special permission for them to get access for the frequently working agency nurses. The staff failed to check in the overflow for the Lidocaine patch, which was in stock, when they did not apply it on 08/08/22. The facility policy Medication Administration dated 03/15/22, included if the medication ordered was not present to notify the charge nurse, check pharmacy delivery sheet for listing, notify pharmacy to request emergency dose, notify the physician, and retrieve the dose immediately. Prior to administering medication, the staff were to check the medication and dosage schedule on the electronic medication administration record and compare with the medication label. The Physician Order Flow Sheet undated, included for all orders to enter the order in the Physician Orders and document the details of the order (name of medication, dose, diagnosis, treatment location, notification of DPOA (Durable Power of Attorney) and the order sent to the pharmacy. The staff were to pull up the medication record/treatment record to ensure the order displayed correctly. The facility failed to process accurate physician orders in a timely manner and failed to administer these medications as ordered by the physician for R20. - The diagnosis tab, located under the attachment link of the dashboard in the electronic medical record (EMR) for Resident (R)31, included a diagnosis of hypertension (high blood pressure). The physician orders tab in the EMR included an order, dated 01/19/22, for Lisinopril (medication used to treat hypertension), 20 milligrams (mg), every day, for hypertension. The Interdisciplinary Notes located in the EMR, dated 08/05/22 at 12:31 PM, revealed Certified Medication Aide (CMA) OO stated R20 received two doses of Lisinopril on 08/04/22 in the morning. The AM slot in the medication cart for R31 had a medication card of Lisinopril that was in current use for the month with a tablet popped out of the packet for 08/04/22 and another full month card for Lisinopril behind the current month card with one tablet popped out for 08/04/22 also. The facility investigation notes revealed both cards of Lisinopril in the AM spot had the tablet for 08/04/22 Popped out. R20 was most likely given two doses of Lisinopril on the morning of 08/04/22. On 08/23/22 at 10:46 AM, CMA S stated she thought she was working when the medication error happened. At the time of the error, overflow medications were kept in an overflow area of the medication cart in the bottom drawer. On 08/25/22 at 10:30 AM, Administrative Nurse F stated before the staff administer a medication, the staff should check to make sure they have the right resident, right medication, right dose, right route, and the right time. On 08/25/22 at 11:42 AM, Administrative Nurse D stated before the staff administer a medication, they should follow the five rights. The facility policy Medication Administration dated 03/15/22, revealed before administering medication, the staff should check the medication and dosage schedule on the electronic medication administration record (eMAR) and compare with the medication label. The label should be read three times when removing the medication from the drawer, before and after pouring, and document on the eMAR after the staff poured the medication. If there was any discrepancy between the EMAR and the label, staff were to check the physician orders before administering the medication. The facility failed to compare the medication to the EMAR for R31 resulting failure to follow the physician order for the resident's Lisinopril with administration of two doses of the medication instead of the ordered one. - The diagnosis tab on the dashboard, located in the electronic medical record (EMR) included diagnoses, for Resident (R) 38 of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), atrial fibrillation (rapid, irregular heart beat), and arteriosclerotic heart disease (thickening of the walls of the arteries that supply blood and oxygen to the heart). The Interdisciplinary Note (ID) note dated 08/22/22 at 01:56 PM, for R38 revealed the staff failed to administer medications to the resident as ordered by the physician, when they administered this resident another resident's medications this morning. The facility investigation notes, for 08/22/22 revealed a Certified Medication Aide (CMA) administered R38 another resident's medications during the morning medication pass. The staff administered Aspirin (nonsteroidal anti-inflammatory medication), Vitamin D3, magnesium, and Zoloft (antidepressant medication). The facility educated the CMA that the resident MAR (medication administration record) has the resident's picture on the top left corner and after the medications are popped out of the card they should immediately be taken to the resident. On 08/23/22 at 10:46 AM, CMA S stated that on 08/22/22 she wrote the name, date, and room number on the medication cups on her medication cart. She had popped the medications for R24 and administered them to R38. CMA S stated she realized she had done that when she returned to the cart to get Miralax (medication used to treat constipation) and saw the medication cup with the room number of R38's. She then reported the mistake immediately to the charge nurse and the director of nursing. On 08/25/22 at 10:30 AM, Administrative Nurse F stated before the staff administer a medication, the staff should check to make sure they have the right resident, right medication, right dose, right route, and the right time. On 08/25/22 at 11:42 AM, Administrative Nurse D stated before the staff administer a medication, they should follow the five rights. The facility policy Medication Administration dated 03/15/22, instructed the staff to identify the resident, and if necessary, verify resident identification with other facility personnel. The facility failed to identify the correct resident before administering medications resulting in the failure to administer R38 the correct medications as ordered by the physician, when R38 received another resident's medications. - Review of Resident (R)4's electronic medical record EMR, under the Diagnoses tab, included a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The revised care plan, dated 03/25/22, instructed staff the resident had an alteration in her thought process due to dementia (progressive mental disorder characterized by failing memory, confusion) and took Aricept (medication used to treat dementia of the Alzheimer's type). Review of a physician's order for R 4, provided by the facility, revealed a new order for Memantine (used to treat moderate to severe dementia of the Alzheimer's type), 5 milligrams (mg), by mouth (po), ordered on 06/05/22. However, review of the resident's Medication Administration Record (MAR), for August 2022, revealed the resident first received the medication on 08/17/22 (over 2 months after the physician ordered it). On 08/24/22 at 11:38 AM, Licensed Nurse (LN) GG stated when a new order comes through, the nurse was to fill out a fax form and send it to the pharmacy for the medication to be delivered. The nurse would then add the new medication to the MAR. On 08/25/22 at 09:41 AM, Administrative Nurse F stated, the charge nurse was responsible for checking for new orders throughout the shift. The facility identified not all new orders were being initiated in a timely manner. On 08/25/22 at 11:10 AM, Administrative Nurse D stated, the facility identified not all new orders were being processed correctly. Administrative Nurse D stated it was the expectation that residents get the medications ordered by their physicians in a timely manner. Review of the facility policy for, process for new orders, undated, included: When receiving a new order, staff were to enter the order into the Physician's Orders in the resident's EMR and fax the new medication order to the pharmacy. Staff were then place a copy of the order into the Medical Records box for follow through. The facility failed to follow physician's orders for over two months, for this dependent resident with Alzheimer's disease. - Review of Resident (R)50's electronic medical record (EMR), under the Diagnoses tab, included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The revised care plan, dated 05/02/22, instructed staff the resident had exit seeking and wandering behaviors. Review of the resident's EMR, under the Orders tab, revealed an order for Risperidone 0.5 mg, po, with dinner, ordered 07/07/22. Review of a physician's order, provided by the facility, revealed a physician's order, dated 07/17/22, for Risperidone (used to treat a certain mental/mood disorders), 0.25 milligrams (mg) with breakfast, by mouth (po), to start on 07/18/22. Review of the resident's Medication Administration Record (MAR), located in the resident's EMR, revealed staff failed to administer the Risperidone 0.25 mg with breakfast, ordered 07/17/22, until the morning of 07/29/22. The resident went 11 days without the ordered medication. On 08/24/22 at 11:38 AM, Licensed Nurse (LN) GG stated when a new order comes through, the nurse was to fill out a fax form and send to the pharmacy for the medication to be delivered. The nurse would then add the new medication to the MAR. On 08/25/22 at 09:41 AM, Administrative Nurse F stated, the charge nurse was responsible for checking for new orders throughout the shift. The facility identified not all new orders were being initiated in a timely manner. On 08/25/22 at 11:10 AM, Administrative Nurse D stated, the facility identified not all new orders were being processed correctly. Administrative Nurse D stated it was the expectation that resident's get the medications ordered by their physician in a timely manner. Review of the facility policy for, process for new orders, undated, included: When receiving a new order, staff were to enter the order into the Physician's Orders in the resident's EMR and fax the new medication order to the pharmacy. Staff were then place a copy of the order into the Medical Records box for follow through. The facility failed to follow physician's orders for change in this dependent resident with behaviors, Risperidone medication. - Review of Resident (R)35's electronic medical record (EMR), under the Diagnoses tab, revealed a diagnosis of constipation (the inability to pass stool). The care plan, revised 05/04/22, instructed staff the resident required limited assistance of one staff for toileting. Review of a physician's order, dated 07/07/22, revealed an order for a KUB (A radiographic scan of the kidney, ureter, bladder and the surrounding structures), due to left lower abdominal pain. Review of an ID Note, in the resident's EMR, dated 08/16/22 (over a month later), revealed the KUB had not been completed. On 08/24/22 at 11:38 AM, Licensed Nurse (LN) GG stated when a new order comes through, the nurse was to note the order and schedule the test with the radiographic company. Staff failed to get the KUB ordered for this resident. On 08/25/22 at 09:41 AM, Administrative Nurse F stated, the charge nurse was responsible for checking for new orders throughout the shift. The facility identified not all new orders were being initiated in a timely manner. On 08/25/22 at 11:10 AM, Administrative Nurse D stated, the facility identified not all new orders were being processed correctly. The facility has done one to one training with nurses and completing training with agency nurses. Administrative Nurse D stated it was the expectation that residents get radiographic examinations ordered by their physicians in a timely manner. Review of the facility policy for, process for new orders, undated, included: When receiving a new order, staff were to enter the order into the Physician's Orders in the resident's EMR and fax the new medication order to the pharmacy. Staff were then place a copy of the order into the Medical Records box for follow through. The facility failed to follow physician's orders for this dependent resident with a history of constipation to timely obtain the KUB for testing. The facility reported a census of 55 residents with 22 selected for review which included 12 residents reviewed for medications. Based on observation, interview and record review, staff failed to follow physician orders for ten of the 12 residents(R)4, R10, R11, R18, R20, R29, R35, R31, R38, and R 50 reviewed for medications. Findings included: - Review of R 10's Physician Order Sheet undated, revealed diagnoses included atrial fibrillation (rapid, irregular heartbeat), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Care Plan, reviewed 07/20/22, instructed staff the resident received Eliquis. The care plan instructed staff if the drug must be discontinued in patients, without adequate continuous anticoagulation, it increased the risk of clotting events such as stroke. A Physician's Order, dated 12/24/21, instructed staff to administer Eliquis (a medication to prevent clot formation) 5 milligrams (mg), twice a day for atrial fibrillation (BID). Review of the Hospital and Surgery Reservation from the vascular surgeon, revealed the resident was scheduled for a vascular procedure on 06/28/22, and it instructed the staff to hold the resident's Eliquis 5 mg, for three days prior to the procedure (06/25, 06/26, 06/27 and 06/28). A Physician's Order, dated 06/28/22, instructed staff to restart the Eliquis 5 mg BID on 06/29/22 in the PM. The MAR contained an entry to hold the Eliquis 5 mg BID on Friday 06/25/22 and to restart the medication pending instructions after the procedure on 06/28/22. Review of the June 2022 Medication Administration Record (MAR) revealed staff did not administer the Eliquis 5 mg BID on 06/24/22 (two doses prior to the ordered stop date of 06/25/22) . Staff did not resume the Eliquis 5 mg for the PM dose on 06/29/22 but administered a PM dose on 06/30/22, (with two more missed doses). Review of the July 2022 MAR, revealed staff did not administer the Eliquis 5 mg on 07/01/22, 07/02/22, 07/03/22, 07/04/22, 07/05/22 and the 07/06/22 AM dose, (with 10 doses missed). Interview, on 08/24/22 at 08:07 AM, with Licensed Nurse (LN) G, revealed staff entered the Eliquis order for this resident wrong into the system. Interview, on 08/25/22 at 09:39 AM, with Administrative Nurse F, revealed she would expect the charge to run a report at the end of their shift to see what meds were not signed for and then to investigate why. Administrative Nurse F stated staff entered the Eliquis 5 mg BID hold date and resumption date into the electronic system incorrectly, and confirmed the resident missed 12 doses of the physician ordered medication. The facility policy Physician Order Flow Sheet undated, instructed staff to enter the order in Physician's Orders, Fax the order to pharmacy, scan the order into the Matrix system, under the correct tab, place a copy of the order in the Medical Records box for follow through, document in note in the Matrix all order details including name of medication dose, diagnosis and pull up the EMAR/TAR and ensure the order displays correctly. The facility failed to ensure staff administered this medication as ordered by the physician to hold and then to restart this resident's Eliquis. - Review of resident (R)11's Physician Order Sheet, undated, revealed diagnoses included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion). Review of the Physician's Orders, revealed the following: On 12/02/20, original order date, Namenda (a medication used for Alzheimer's disease) staff to administer 10 milligrams (mg) twice a day (BID). On 03/17/22, original order date, Zoloft (an antidepressant), 100 mg, daily for major depressive disorder. Review of the July 2022, Medication Administration Record (MAR) revealed staff did not administer Zoloft 100 mg for the morning doses as ordered by the physician, on 07/13/22 through 07/18/22, (for a total of six missed doses of the medication). Review of the July 2022, MAR revealed staff did not administer Namenda 10 mg, for the morning dose on 07/13, 14,16,17, and 07/18/22. (a total of five missed doses.) Staff did administer the AM dose on 07/15/22. Interview, on 08/24/22 at 11:30 AM, with Certified Medication Aide (CMA)R, revealed CMAs should check in the medication room for over flow medications to replace medications that were out. CMAs were responsible to order medications in a timely manner. Interview, on 08/25/22 at 09:39 AM, with Administrative Nurse F, revealed she would expect the charge nurse to run a report at the end of their shift to see what meds were not signed for and then to investigate why. She would expect the CMAs to check the medication room for the medications and if they were not available, to follow up with the charge nurse/pharmacy. The facility policy Teachable Moment, dated 06/23/21, instructed staff to not wait until the medication is gone before reordering. If electronic reorders have not arrived, call the pharmacy to see why and/or reorder. The facility failed to ensure staff ensured timely reordering of medications and investigate medications not administered at the end of each shift to ensure this resident received the medications as ordered by the physician. - Review of resident (R)18's Physician Order Sheet, undated, revealed diagnoses included dementia progressive mental disorder characterized by failing memory, confusion) and major mood disorder (major mood disorder). A Physician's Order, dated 05/19/22, instructed staff to administer Seroquel (an antipsychotic) 25 milligrams (mg) every hour of sleep for hallucinations. Review of the May 2022 Medication Administration Record, (MAR) revealed staff administered Seroquel 25 mg every hour of sleep beginning 05/24/22 (five days after the facility received the order). Review of the June 2022 MAR, revealed two missed doses of Seroquel on 06/18/22 and 06/19/22. Interview, on 08/24/22 at 11:30 AM, with Certified Medication Aide (CMA) R, revealed CMAs should check for medications in the medication room. If the medication was not available staff would need to notify the charge nurse and reorder the medication from the pharmacy. Interview on 08/25/22 at 09:39 AM, with Administrative Nurse F, revealed she expected the charge nurse to run a report at the end of their shift to see what meds were not signed for and then investigate why. She would expect the CMAs to check the medication room for the medications and if they were not available, to follow up with the charge nurse/pharmacy. Administrative Nurse F stated staff ordered the medication for Seroquel on 05/19/22, with the wrong code and it did not transfer correctly onto the MAR. The Physician Order Flow Sheet, undated, instructed staff to pull up the e MAR/TAR and ensure the order displays correctly. The facility failed to ensure this resident received Seroquel as ordered by the physician. - Review of resident (R)29's Physician Order Sheet, undated revealed diagnoses included cerebral vascular infarction (stroke), major depressive disorder (major mood disorder), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). A Physician's Order, dated 06/17/22, instructed staff to discontinue Wellbutrin SR (an antidepressant sustained release) 100 milligrams (mg) twice a day, and to then start Wellbutrin XL (extended release) 300 mg, every morning for major depressive disorder. Review of the June 2022 Medication Administration Record (MAR) revealed an entry for Wellbutrin SR (not the ordered XL type of medication) 300 mg daily for bipolar disorder. Staff administered this incorrect medication on 06/18/22, 06/21/22 and 06/22/22 through 06/30/22, (with incorrect administration for a total of 13 doses). Staff failed to discontinue the Wellbutrin SR as ordered on 06/17/22. Review of the July 2022 MAR revealed an entry for Wellbutrin SR (not the ordered XL type of medication), 300 mg once a day for major depressive disorder. Staff administered this incorrect ordered medication from 07/01 through 07/25/22, for a total of 25 doses. Interview, on 08/24/22 at 11:30 AM, with Certified Medication Aide (CMA) R, revealed CMAs should check for medications in the medication room. If the medication were not available staff would need to notify the charge nurse and reorder the medication from the pharmacy. Interview on 08/25/22 at 09:39 AM, with Administrative Nurse F, revealed staff entered Wellbutrin SR 300 mg daily instead of Wellbutrin XL 300 mg daily into the electronic medical record which caused the incorrect MAR entry for Wellbutrin SR 300 mg. The error was caught when another provider instructed staff to discontinue Wellbutrin SR 300 mg and start Wellbutrin XL 300 mg on 07/21/22. Administrative Nurse F stated the facility was aware of the medication errors. The facility policy Physician Order Flow Sheet, undated, instructed staff to pull up the e MAR/TAR and ensure the order displayed correctly. The facility administered this resident's Wellbutrin SR 300 mg daily instead of Wellbutrin XL 300 mg daily as ordered by the physician, for a total of 38 doses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 39 residents with 14 residents sampled, including three residents reviewed for Activities of Daily Living (ADL). Based on interview, record review, and observation, the facility failed to ensure one of the three sampled residents, Resident (R)16 received appropriate personal hygiene care assistance regarding facial shaving. Findings included: - Review of Resident (R)16's electronic medical record (EMR) revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. He had rejection of care one to three days of the assessment period. He required extensive assistance of one staff for personal hygiene and required physical help of one staff for bathing. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/27/21, did not trigger. The quarterly MDS, dated 01/26/21, documented the resident had a BIMS score of nine, indicating moderate cognitive impairment. He had rejection of cares 1-3 days of the assessment period. He required extensive assistance of one staff for personal hygiene and total assistance of one staff for bathing. The ADL care plan, dated 10/27/17, instructed staff the resident required one staff assistance for showers. No instruction was given for shaving the resident's facial hair. The Behavior care plan, dated 10/27/17, instructed staff the resident may refuse showers at times. If the resident refused his shower, staff were to offer a spit bath in the bathroom. Review of the resident's EMR revealed daily charting which indicated the staff checked and trimmed the resident's facial hair, as needed (PRN). Review of the resident's EMR revealed documentation the resident received two showers per week, as care planned. On 06/23/21 at 01:45 PM, the resident sat in a recliner in the commons area watching TV. The resident was unshaven. On 06/24/21 at 08:29 AM, the resident sat at the dining room table for breakfast. The resident remained unshaven. On 06/24/21 at 11:34 AM, the resident sat at the dining room table awaiting lunch. The resident remained unshaven. On 06/29/21 at 07:52 AM, Certified Nurse Aide (CNA) M, got the resident up for the day. The resident remained unshaven when taken to the dining room for breakfast. On 06/29/21 at 02:41 PM, CNA M and Certified Medication Aide (CMA) N, assisted in transferring the resident from a recliner to his wheelchair in the commons area. The resident remained unshaven. On 06/29/21 at 07:52 AM, CNA M stated, residents were to be shaven on their shower days, but it was not always done. This resident received showers on the evening shift. CNA M stated she was going to shave him the day before but had not. The resident did not refuse cares. On 06/29/21 at 02:47 PM, CNA Q confirmed, the resident was unshaven. CNA Q stated the resident did not refuse cares. On 06/29/21 at 02:24 PM, Licensed Nurse (LN) G stated, staff were to shave residents on their shower days or whenever requested. The resident did not refuse cares. On 06/30/21 at 09:40 AM, Administrative Nurse D stated, staff are to shave residents on their shower days. The facility lacked a policy regarding when a resident should be shaven by the staff. The facility failed to provide assistance as needed for facial shaving for this dependent resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 39 residents with 14 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure one of the five sampled residents, Resident (R) was kept free from accidents, regarding unsafe transfers and lack of foot pedals on his staff propelled wheelchair. Findings included: - Review of Resident (R)16 electronic medical record (EMR) revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. He required extensive assistance of two staff for transfers. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/27/21, did not trigger. The quarterly MDS, dated 01/26/21, documented the resident had a BIMS score of nine, indicating moderate cognitive impairment. He required extensive assistance of two staff for transfers. The ADL care plan, dated 10/27/17, instructed staff the resident required the sit to stand lift in his room with assistance of two staff, and two staff assistance without the lift in the commons area. The resident used a wheelchair for locomotion on the unit with assistance of one staff. The resident was unable to propel himself in the wheelchair. Review of the resident's electronic medical record (EMR) from 06/02/21 through 06/29/21, revealed the resident required extensive to total assistance of 1-2 staff with transfers. The resident required total assistance of one staff for locomotion on the unit with his wheelchair. On 06/29/21 at 10:51 AM, Certified Nurse Aide (CNA) M and CNA N, transferred the resident from the recliner in the commons area to his wheelchair. Staff used a gait belt and extensive assistance during the transfer. The resident was unable to bear any weight on his flexed legs during the transfer, making it an unsafe transfer. On 06/29/21 at 10:51 AM, CNA M stated, the resident did not always bear weight on his legs during transfers. On 06/29/21 at 02:47 PM, CNA Q stated, the resident was only able to bear minimal weight during transfers. Sometimes he could not bear weight at all while being transferred without the sit to stand lift. On 06/29/21 at 02:24 PM, Licensed Nurse (LN) G stated, the resident needed to be able to bear weight on his legs in order for a transfer with or without the sit to stand lift to be considered safe. Staff should not transfer the resident without a sit to stand lift if the resident was unable to bear some weight on his legs. On 06/30/21 at 09:40 AM, Administrative Nurse D stated, a resident would need to bear weight for a sit to stand lift to be used safely or for staff to transfer a resident without the use of a lift. Furthermore, on 06/29/21 at 07:52 AM, CNA M, propelled the resident in his wheelchair from his room to the dining room. The resident wore house slippers which skimmed along on the floor during the transport. The wheelchair lacked foot pedals. On 06/29/21 at 10:51 AM, CNA N, propelled the resident from the commons area to his room. The resident wore house slippers which skimmed the floor during the transport. The wheelchair lacked foot pedals. On 06/29/21 at 07:52 AM, CNA M, confirmed the resident's feet skimmed the floor during transport. Staff M stated, the resident did not have foot pedals for his wheelchair. He was unable to propel himself in the wheelchair. On 06/29/21 at 02:47 PM, CNA Q stated, staff were to use foot pedals when propelling him in the wheelchair. On 06/29/21 at 02:24 PM, LN G stated, staff should use foot pedals for residents who were unable to propel themselves in their wheelchairs. Residents' feet should not skim the floor during transports. On 06/30/21 at 09:40 AM, Administrative Nurse D stated, she would expect staff to use foot pedals on resident wheelchairs when the resident was not able to propel themselves. A policy regarding safe transfers of residents unable to bear weight and for safe transports of residents unable to hold their feet off of the floor were not made available. The facility failed to provide safe transfers for this dependent resident who was unable to bear weight on his legs. The facility also failed to provide safe transports for this dependent resident, unable to hold his feet off of the floor, while being propelled in his wheelchair.

The facility reported a census of 39 residents. Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility. Findings included: - Observation, on 06/29/21 at 02:57 PM, with Dietary Staff BB revealed the following items of concern: 1. Two plastic utensil storage carts, contained five drawers that contained debris on the interior bottom of the drawers on which the spoons, serving scoops and various food utensils directly sat on. 2. The metal cook's preparation table contained a metal utensil storage drawer that contained debris and a wet substance on the interior bottom of the drawer with spatulas, bowl scrapers, spoons,and measuring spoons directly on the surface. 3. The exterior of the two large plastic mobile sugar and flour bins contained a build-up of gray and black discolorations and debris around the lids. 4. Five nonstick coated small skillets contained interior surface scratches and build-up of black substances. Interview, on 06/29/21 at 03:15 PM with Dietary Staff BB, revealed dietary staff had a daily cleaning schedule for the drawers and flour and sugar bins but confirmed the drawers and bins needed a thorough cleaning. Dietary Staff BB confirmed the five nonstick skillets contained interior surface scratches. The Daily Cleaning Schedule, undated, instructed staff to wipe and sanitize the cooks' cart and flour/sugar bins. The facility policy, Sanitation revised 03/07/19, instructed staff to maintain the food service area in a clean and sanitary manner. The facility failed to store, prepare, and serve food in a sanitary manner for the residents of the facility.